全面无纸化在住院信息化建设中的应用研究  

Application study on comprehensive paperless model in hospital informationization construction

作　　者：钟文明[1] 刘叶珍[1] 吴智娟[1] 石继伟[1] 刘晓峰[1] 周华[1] 

机构地区：[1]深圳市宝安区妇幼保健院信息科,广东省518133

出　　处：《中国医院统计》2013年第4期248-250,共3页Chinese Journal of Hospital Statistics

基　　金：深圳市科技局课题（201103054）

摘　　要：目的探讨病房无纸化建设及无纸化电子病历建设的构成要素。方法实施基于临床路径的半结构化新型电子病历，解决电子病历系统与各子系统的通讯，支持医护移动查房，解决医患数字签名问题，满足患者查询健教需求，电子病历实施无纸化存储与管理。结果病房无纸化建设是一个系统工程，其关键是无纸化电子病历，只有解决了以上各种问题，病房全面无纸化才能成为可能。结论病房全面无纸化建设，有利于实现病历无纸化归档，降低医疗成本、提高工作效率、增加经济效益和社会效益。Objective To explore constituents of paperless construction content of hospital room and paperless electronic medical record （EMR） system. Methods We carried out semi-structured EMR based on clinical pathway, solved communica tions between EMR and different subsystem, supported mobile ward round of doctors and nurses, realized digital signature of doc- tors and patients, satisfied patients＇ requirement of inquest and health education, and at last, EMR was enforced paperless stor- age and management. Results Paperless model construction of ward was a systematic engineering, and its key point was paper-less EMR. Only problems when these problem are solved, could paperless model construction of ward be possible. Conclusion Comprehensive paperless model construction of ward can make paperless medical records come true, cut down medical cost, rai ses working efficiency, increase economic returns and social benefits.

关 键 词：无纸化 临床路径 半结构化 电子病历 管理模式 

分 类 号：R155[医药卫生—营养与食品卫生学]